Description of the condition
The spread and volume of HIV care and treatment services has increased markedly in low and middle-income countries (LMIC). As of mid-2011, over 6 million people were receiving antiretroviral therapy (ART) in LMIC. In spite of progress to date, the global coverage for ART is still below 50% (UNAIDS 2011). The current rate of enrolment of patients on ART is insufficient to reach the global goal.
An effective service needs HIV testing and counselling services to be linked to HIV care and treatment; requires ART initiation as early as recommended by WHO; and a service that retains patients. This will help decrease AIDS-related mortality, reduce costs and maximize efficiency gains, and avert new infections (Ford 2011). Yet there are a number of constraints at all of these steps; for example, recent systematic reviews have indicated that, for those who do initiate ART, retention in care is a major challenge, with around 30% of patients estimated to be lost to follow-up within 24 months of initiating ART (Fox 2010). Access to care appears to be an important driver of poor retention, with transport costs, time spent travelling to health facilities, and time waiting for services at health facilities all cited as reasons for defaulting (Kagee 2011; Miller 2010; Ware 2009).
Description of the intervention
In order to increase access to care -- both to allow more people to be treated, and for those that are in care, to improve retention -- a number of countries have introduced two important, linked adaptations to the traditional, "Western-based" model of care provision: first, the "task shifting" of treatment from more highly trained specialists and medical practitioners to nurses; secondly, the decentralisation of ART care delivery from hospitals to more peripheral health facilities.
Task shifting is the process whereby specific tasks are transferred to different cadres of health workers who have had less training and have fewer qualifications. Task shifting aims to make efficient use of existing health care workers in order to ease delays in service delivery (WHO 2008). Task shifting may also include the delegation of clearly-outlined duties to various levels of health workers who receive specific, skills-based training. Task-shifting should result in an equivalent standard of care to that provided by higher cadres of health workers. There are trials and systematic reviews and reports that nurses can provide care that is at least as good as that provided by physicians (Laurant 2004; Sanne 2010).
Decentralisation of care is key for efficient service delivery, including increasing access to care for large numbers of patients not yet in care, and facilitating treatment closer to the homes of patients, thereby improving convenience and reducing travel costs. The overall aim is to improve retention in care, which is a critical outcome for successful and sustained HIV/ADS treatment. This review primarily interrogates the value of decentralisation of care, and the related programmatic indicator of success, retention in care. Task shifting is being addressed by a separate Cochrane review (Araoyinbo 2008).
How the intervention might work
The benefits of decentralisation include increased access to care, which, in turn, may improve health outcomes: it may increase the individual patient attention by nurses and counsellors, as there may be lower staff to patient ratios; and the point of care may be closer to the community, and the increased access may reduce defaulting and treatment failure (Fatti 2010).
On the other hand, there is legitimate concern that the provision of care at lower levels of the health service may result in decreased quality of care and poorer clinical outcomes (Decroo 2009). Given these uncertainties, the extent to which HIV/AIDS treatment is available via decentralised services varies considerably between and within countries. There is a need for clarity around the risks and benefits of decentralising ART service in order to inform future operational guidance.
One of the problems in cross-national comparisons of HIV care is in terminology. First, with terminology of health services, and secondly with models of decentralisation. For health services, the problem is that "community," "health post," "health centre" and "hospital services" vary in meaning and in what they represent between countries. For example, a health centre in Tanzania has paramedical staff, and is equivalent to a district hospital in Thailand.
In this review, we define each "tier" in the health system by the staffing configuration they have (Table 1). Thus, for community, the care is provided by someone with only a few months training; for a health centre, this is led by a paramedic or nurse; for a hospital, it is led by a doctor; and for an advanced hospital, there are specialist doctors present. In the table we also define community in three categories: family member, village volunteer, or a primary health care clinic with a nurse aide or community health worker. At community care level, systems may thus be established to deliver treatment at household level. This framework is to help describe different programmes, but it may be modified in the light of models identified in the literature.
|Tier||Highest cadre||Terms often used||Facility and staff||Equipment facilities|
|Community||Individual with maximum of few months training; paid or unpaid||1a. Family led care||Family member|
|1b. Village volunteer||Trained volunteer; health assistants||HIV tests, counselling, replenish drugs|
|1c. Primary care clinic||Nurse aide or community health worker with a few months training|
|Health centre||Paramedic or nurse (2+ years training)||Health centres; district hospitals||Purpose built with at least one paramedic or nurse with some health assistants||HIV tests; antiretrovirals; opportunistic infections medicines; point of care laboratories|
|Hospital||Doctor||Health centres; district hospitals||Purpose built with at least one medical doctor with nurses / paramedics and assistants|
Not viral load
|Advanced hospital||Specialist doctor||District hospital; referral hospital||Purpose built with at least 2 specialist doctors with nurses / paramedics and assistants||Viral load and full investigations|
For HIV care, the emerging models are giving rise to a variety of terms, such as "decentralised," "down referral," and "delocalised." To help classify models and allow cross study comparisons, we have developed a nomenclature (Table 2). This is not meant to be definitive and may need to be modified as the models of care develop, but provides a working framework for this review.
|Our term||Initiation||Follow up|
|Standard hospital model||Hospital||Hospital|
|Down referral (partial)||Hospital||Health centre|
|Down referral (full)||Health centre||Health centre|
|Delocalised||Health centre (weekly clinics with hospital staff)||Health centre (weekly clinics with hospital staff)|
Primary (tier 1c)
Primary (tier 1c)
(monitor six monthly by health centre)